Who Provides Therapy? Individuals who provide speech
therapy are called Speech-Language Pathologists (SLPs). SLPs usually have at
least master's level graduate training (they must have a master's degree to be
certified by the American Speech-Language-Hearing Association, ASHA). Similar
to medical doctors, SLPs usually specialize in certain areas and with certain
age groups -- for example, childhood speech and language disorders, adult
language disorders, voice disorders, cleft palate or craniofacial disorders. A
parent of a child with a repaired cleft palate should seek the services of a
SLP who works extensively with children. (Although experience with cleft palate
is a plus, it is not required in all cases). The SLP that you select should not
only be knowledgeable about childhood speech disorders, but also possess good
interpersonal skills and be able to relate well to children. Don't be afraid to
trust your instincts. (And don't be afraid to change therapists if one doesn't
seem right for your child).

Therapy for What? This might
seem like a silly question, but it is perhaps the most important one to ask. In
the traditional sense, speech therapy is meant to help children who have
disorders of speech and/or language. In my local newspaper (Cary, NC), an
advertisement for a SLP states that services are provided for problems such as
"lisping" and "baby talk." While children with
repaired cleft palate may "lisp" and/or use "baby talk," they may do so for different reasons than children
without cleft palate. The key is for the SLP to know which
problems can be successfully treated and which ones cannot be successfully
treated.

Developmental Articulation and/or Phonology
Problems. SLPs know that
approximately 6 to 10% of all children (boys somewhat more frequently than
girls) will exhibit difficulty in learning the sounds of English and will
require speech therapy. (This therapy is usually provided through the
school). Most of these children will have no obvious structural problems
with the ears, mouth, or throat, yet they will omit, distort, or
substitute certain speech sounds. The reason for such errors might be
related to subtle problems with hearing and/or motor control of the speech
articulators. Regardless of cause, the majority of these children will
learn to correct their speech errors through therapy and go on to lead normal
lives. Children who are born with cleft lip and/or palate are not immune
from these types of speech problems. If a child with a repaired cleft palate
has these types of speech problems, then traditional types of speech
therapy should be successful -- assuming that palatal surgery was
successful.

At
times, a young child with repaired cleft palate may use primarily nasal
substitutions. That is, the phonemes /m/ and /n/ are used pervasively for all
oral pressure consonants. Speech therapy should always be initiated in
these cases before recommending additional surgery, or even objective
assessment. As noted by Peterson-Falzone et
al. (2001), “Only when the child is attempting to produce pressure consonants
can velopharyngeal function be adequately assessed”
(p. 239).

Compensatory Articulation Errors Related To Cleft
Palate. For reasons not
completely understood, some children with repaired cleft palate will
develop "compensatory" articulations. Typically, this means that
the child will produce sounds farther back in the mouth (or throat) than
is normal. For example, instead of using the lips to block air and produce
a /p/ sound, the child might use the vocal cords as a substitute (called a
"glottal stop" substitution). Other compensatory errors might
involve making the /s/ sound in the throat with the back of the tongue
rather than in the mouth with the front of the tongue (called a
"pharyngeal fricative" substitution) or even snorting air
through the nose for /s/ (sometimes called a "nasal fricative").
Compensatory errors such as glottal stops and/or pharyngeal fricatives can
make a child's speech quite unintelligible if used frequently.

The
presence of compensatory articulations in a young child with repaired cleft
palate is usually but not always a sign that palatal surgery was ineffective.
The use of glottal stops, for example, is an effective way to circumvent the
inability to impound oral air pressure due to velopharyngeal
inadequacy (VPI). VPI is the inability of the soft palate to make contact with
the upper throat wall to close off the nose during speech. This usually occurs
in a child with repaired cleft palate because the soft palate is too short
and/or does not move well enough. Additional surgery will most likely be
required if the soft palate moves well but is too short. Speech therapy, however, will be
needed to correct compensatory articulations. Many SLPs will tell
parents that they cannot do anything to help the child until additional surgery
is completed. Unfortunately, this is a myth. Ideally, speech therapy should
begin before additional surgery in order to establish correct oral
placement for sounds. Many parents – and some SLPs – may think this is
counter-intuitive. If VPI caused the compensatory errors, then how can they be
corrected before additional surgery? If a child is old enough, speech therapy
can be effective to teach the child to use the lips versus the vocal folds to
make sounds such as /p/. This may not be easy depending upon the child but it can
be done! The SLP may need to occlude the child’s nose during therapy to prevent
nasal air escape and allow the child to focus on correct placements for
articulation.

Retained compensatory errors. If speech therapy is
not started prior to additional surgery, then it is likely that the child will
persist in using compensatory articulations following surgery. Assuming that
palatal surgery was successful, speech therapy is needed to correct retained
errors. [Below are some resources that SLPs might find helpful when attempting
to remediate compensatory errors].

Obligatory Hypernasality, Weak Pressure
Consonants, and/or Audible Nasal Air Emission Related To Cleft
Palate. Often, following
initial palate surgery (and sometimes following secondary palatal
surgery), children will sound "nasal" and/or audible puffs of
air will escape from the nose while talking. Even if the child does not
have articulation errors, the degree of hypernasality and/or nasal
emission may cause speech to be difficult to understand and/or present
social problems. Often, well-meaning physicians will prescribe speech
therapy for these symptoms. Parents and SLPs, however, need to be
informed that speech therapy -- even by the most experienced pediatric
craniofacial SLP -- will probably not correct these problems.
These symptoms are the result of inadequate physical separation of
the mouth and nose by the soft palate (i.e., VPI due to a structural
problem). Surgery, not speech therapy, is needed to correct this
condition.

Having
said the above, under some circumstances, a SLP might
attempt speech therapy to reduce symptoms of hypernasality,
weak pressure consonants, and/or nasal air emission on a trial basis.
Typically, a child may benefit if the symptoms are mild and/or inconsistent.
For example, a child may sound especially nasal late in the day when tired. There
are several speech therapy techniques that are designed to mask or cover-up
symptoms of hypernasality and/or audible nasal air
emission. These techniques include a) talking louder and/or opening the mouth
more while talking to reduce hypernasality, and b)
making light and quick contacts of the lips and tongue while talking to reduce
nasal air escape. A basic problem with these techniques is that the child is
required to consciously monitor how he/she is talking. Typically, children --
especially young children -- are not willing to monitor speech for extended
periods of time.

Trial speech therapy may also be tried in cases where additional
palatal surgery has already been done but obligatory symptoms of hypernasality, weak pressure consonants, and/or audible
nasal air emission persist. In these cases, nostril occlusion may be employed
to facilitate tactile and auditory awareness of oral air pressure build up and
release. If the child cannot maintain oral air pressure without nostril
occlusion in a reasonable period of time, then therapy should be discontinued.

Finally, because the soft palate consists of muscles, many SLPs
will attempt muscle strengthening exercises. Typically, these exercises consist
of non-speech tasks such as blowing, sucking through a straw, or eliciting a
gag reflex. The thinking behind these approaches is that increased muscle
strength obtained during these exercises willcarryover to speech. Although this idea seems
intuitive, there is little scientific evidence to show that non-speech muscle
strengthening exercises actually reduce hypernasality and/or nasal air
emission. Parents should be leery of non-speech oral motor exercises recommended
for hypernasality.

Sound Distortions Due to Dental Malocclusion. Typically, many children with repaired clefts
that involve the gum ridge (alveolar ridge) will distort the sounds
"s zch
j (as in “judge”) sh zh." These sounds are called
"sibilants." To produce these sounds, air must flow over
the tongue and strike the front teeth. This causes the air to become
turbulent (a hissing-like sound). If teeth are missing or misaligned
(malocclusion), then the air flow may escape before striking the front
teeth. Many children with repaired cleft palate have restricted (or
collapsed) upper dental arches. This condition may cause a cross-bite
(upper teeth not meeting lower teeth) that allows lateral escape of air
and sound distortion (called a "lateral lisp"). Zajac et al.
(2012) has also reported that collapsed upper dental arches are associated
with backing of sounds such as /t/ and /d/. Depending upon the type and
severity of malocclusion, speech therapy might help some children with
sibilant distortions or backing errors. The child, however, will need to consciously
monitor his/her speech in order to eliminate the error. As indicated
above, most young children tend not to do this. Following orthodontic
treatment of the underlying dental malocclusion, one might expect that
children would spontaneously self-correct sibilant distortions and/or
backing errors. This may or may not occur. Obviously, the benefits of
speech therapy should be greater following orthodontic treatment.

The following books provide both general information and specific techniques
that might be used to treat compensatory articulations, hypernasality
and/or nasal air emission, and dental-related sound distortions: